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Abstract

Background

HIV prevalence in north-east India is high and injecting drug use (IDU) is common.
Due to HIV-related deaths there are increasing numbers of IDU widows, many of whom
are HIV infected, and experiencing poor health, social isolation, discrimination and
poverty, all factors likely to be compromising their mental health. There is increasing
recognition of the links between HIV and mental health.

Methods

The aim of this study was to pilot a peer-facilitated, participatory action group
(PAG) process and assess the impact of the intervention on the mental health of participants.
The intervention consisted of 10 PAG meetings involving 74 IDU widows. Changes in
quality of life (WHOQOL-BREF), mental health (GHQ12) and somatic symptoms were assessed.
The value of the intervention from the perspective of the participants was captured
using a qualitative evaluation method (Most Significant Change).

Results

Participants' quality of life, mental health and experience of somatic symptoms improved
significantly over the course of the intervention, and the women told stories reflecting
a range of 'significant changes'.

Conclusion

This pilot intervention study demonstrated that a participatory approach to mental
health promotion can have a positive impact on the lives of vulnerable women, and
the potential to contribute to HIV prevention. Further investigation is warranted.

Background

The north-east Indian states of Manipur and Nagaland are characterised by political
instability, unemployment, and easy availability of heroin from across the Myanmar
border. They are classified by the National AIDS Control Society [1] as high prevalence states for HIV, and intravenous drug use is an important route
of HIV transmission [1,2]. The injecting drug user (IDU) population in these states constitutes 1.9–2.7% of
the adult population [2]. In 2005, the HIV prevalence among IDUs in Manipur and Nagaland was reported to be
24% and 5% respectively, representing an increase in both states from the previous
year [1]. However, much higher rates have also been reported: in a sample of IDUs from north-east
India, 75% were found to be HIV positive [2]. Most IDUs in north-east India are men, an estimated 40% are married [3], and death rates have been high in the last five years, consequently the number of
widows of IDUs has increased.

Widows in India are socially and economically disadvantaged, and the situation for
widows of IDUs is often worse. They are frequently stigmatised on three levels – for
being a woman, being a widow, and being HIV positive [4]. In 2004, a situation assessment of widows of IDUs conducted in Manipur found that
they were faced with a range of psycho-social, economic and health problems. Many
IDU widows and their children were HIV-infected and experiencing poor health, social
isolation, grief, loneliness, discrimination, and poverty; all factors likely to be
compromising their mental health [5]. Some widows reported engaging in HIV risk behaviours including alcohol and drug
misuse, sex work and unprotected sex. Accessing HIV prevention services was not a
priority for these women who were predominantly concerned about livelihood and their
children's future [5].

Mental health is more than simply the absence of mental illness; it is the foundation
for well-being and effective functioning for individuals and communities [6]. Mental illness is associated with indicators of poverty including low levels of
education, poor housing and low income [7], and with other illnesses such as HIV infection [8]. Substance misuse, violence and health problems such as HIV and depression are more
prevalent and more difficult to cope with in conditions of low income, limited education
and unemployment [9].

The nexus between gender and mental health is well recognised. Socio-cultural beliefs
about gender roles often diminish women's control over their own lives and restrict
their access to economic resources and power within the society, and this in turn
has a significant effect on their mental health status and the risk of mental illness
especially depression [10-12].

The influence of gender on women's mental health is most evident in relation to depression.
Globally, including in India, women are approximately twice as likely as men to experience
depression and widows in India are more likely to suffer from mental illness than
single or married women [10-12]. There is a need to promote the mental health of women in general and of widows in
particular, both in India and further a field [12].

Mental health is associated with HIV in a range of ways. In relation to engagement
in HIV risk behaviours, individuals with poor mental health as a group and including
those with untreated mental illness and substance misuse problems, have a greater
chance of exposure to HIV related risk behaviours. Many have less control over their
lives than other populations, are more likely to find themselves in situations of
risk, and have diminished ability to negotiate safe behaviours [13,14]. Interactions between drug and alcohol use and depression are common, and studies
in India indicate that the former is associated with engagement in HIV risk behaviours,
especially among those with mental health problems [15,16]. People living with HIV and AIDS have an increased risk of developing mental health
problems including depression and substance misuse [13-15]. These conditions adversely affect HIV and AIDS treatment adherence, contribute to
risk behaviours and exacerbate social difficulties associated with stigma and discrimination.
These considerations raise the possibility that promoting the mental health of vulnerable
groups may reduce the risk of engagement in HIV risk behaviours and thereby contribute
to HIV prevention.

Emerging evidence indicates that mental health can be promoted by public health actions
with vulnerable groups [6]. Just as physical health can be promoted, so too can mental health. A recent WHO
report draws on a public health framework proposed initially by the Victorian Health
Promotion Foundation [17] that identifies three key social and economic determinants of community and individual
mental health: (1) social inclusion; (2) freedom from discrimination and violence;
and (3) access to economic resources. This framework recognises that psychosocial
and economic factors influence (protect or negate) a number of health-related behaviours
such as substance misuse and risky sexual behaviours, that in turn affect all areas
of health, including mental health [16,17].

While the health benefits of community participation are well understood in development
work, health policy does not always reflect this, partly because the published evidence
related to this approach is limited. Our intervention drew on participatory action
research (PAR) approaches to health development that seek to empower target communities
to actively identify problems and develop solutions in relation to particular research
questions. This enhances their self-confidence and leadership skills, and assists
them to address their own health and social needs [18,19]. For example, a study in Nepal demonstrated that community based participatory action
had a significant positive impact on maternal and infant mortality [20]. Studies such as these and the one described in this paper help to narrow the evidence
gap on the effectiveness of community participation to contribute to changes in health
status.

This pilot intervention study began with the hypothesis that the implementation of
structured and peer-facilitated participatory action groups (PAGs) among widows of
IDUs in Manipur and Nagaland, with a focus on promoting mental health and well-being
and informed by a strengths-based approach [21], would be associated with: (1) improved mental health; and (2) a reduced likelihood
of engagement in HIV risk behaviours.

The objectives of the study were to: (1) learn about the women's perspectives on mental
health and well-being and the links between mental health and HIV; (2) assess changes
in the women's quality of life and mental health during the course of the intervention;
(3) assess changes in engagement in HIV risk behaviours; (4) describe the process
and outcome of the intervention from the perspective of the women; (5) document the
process of establishing and conducting the intervention so it can be repeated or adapted
in the future. This paper reports on the findings in relation to objectives 2, 3 and
4. A full description of the background, the intervention and the methods for this
study has been published elsewhere [22], so the following methods section is brief.

Methods

Six groups of IDU widows were established (three in each state) in mid 2006, with
9–16 widows in each group. The women were recruited through partnerships with local
non-government organisations (NGOs) working in the field of HIV prevention. The NGOs
contacted IDU widow's known to them, and through these women's networks, contacted
other widows. All interested widows attended a meeting where the nature of the study
and intervention were explained, and those women interested in participating were
recruited. The districts covered by the participating NGOs were Imphal and Churachandpur
in Manipur and Dimapur and Kohima in Nagaland. The intervention is described elsewhere
[22] and more information is available from the authors on request. In brief, the intervention
was based on the framework for mental health promotion [17], and consisted of ten peer-facilitated PAG meetings that were held every fortnight
for half a day over a twenty week period. All meetings were participatory, strengths-based
and comprised of a combination of structured activities and open discussion (Table
1). Two peer facilitators were trained and supported for each group, and were provided
with flexible written guidelines for each session. The women's travel and childcare
costs were covered, refreshments were provided, and the activities deliberately engendered
fun and enjoyment for the women. Each group participated in an action planning process
to develop strategies for promoting mental health and the sustainability of the groups.
A range of quantitative and qualitative data was collected to assess the impact of
the intervention on the lives of the women.

Three brief questionnaires were completed by the women during the first and last PAG
meetings:

1. The short version of the WHO Quality of Life questionnaire (WHOQOL-BREF): Quality
of life is a broad ranging concept and is assessed on a person's perceptions of various
factors divided into four domains: (i) Physical health domain including pain and discomfort,
energy and fatigue, mobility, sleep and work capacity; (ii) Psychological domain including
spirituality, body image and appearance, thinking and learning and self-esteem; (iii)
Social domain including personal relationships, sexual activity and social support;
(iv) Environment domain including physical safety and security, physical environment
(pollution, climate), financial resources, participation in recreation, home environment,
transportation, and access and quality of health and social care [23,24]. Cronbach alpha values for each of the domain scores in the WHOQOL range from 0.71
to 0.86, demonstrating good internal consistency [25].

2. The General Health Questionnaire (GHQ12): The GHQ12 is a screening instrument for
common mental disorders suitable for use in community, primary care and medical settings.
It is used in many different countries and although the original version consisted
of 60 items; shorter versions have been subsequently developed and validated [26]. The Cronbach's alpha for the GHQ12 is estimated to be between 0.82 – 0.86 [26]. Analysis of the GHQ12 data used a cut-off of three points, greater than three indicating
potential presence of a common mental disorder such as depression or anxiety. The
selection of this cut-off was based on findings from an earlier study using the GHQ12
in an Indian setting [27].

3. A Health and Well-being Questionnaire; Women in India who experience mental health
problems such as depression often express their distress as somatic symptoms [28-30], so this questionnaire was adapted from an existing somatic symptom scale [31]. It asked participants to select how often they experience pain, various bodily sensations
(e.g. weakness, trembling), disturbances of body functions (e.g. sleep, appetite),
and reproductive symptoms (e.g. menstrual disturbance, vaginal discharge), as an indication
of mental health. The second part of the questionnaire consisted of a small number
of questions about sexual partners and drug and alcohol use adapted from a widely
used Behavioural Surveillance Survey [32].

The WHOQOL-BREF and the GHQ12 are usually self-administered but assisted administration
is possible for people with low literacy. All questionnaires were translated into
the local languages, back translated and piloted with literate and non-literate women.
The research teams and peer facilitators assessed the sensitivity and appropriateness
of all questions before they were included in the study. Special attention was given
to the more sensitive questions seeking information about sexual and substance use
behaviours.

Data were analysed using SPSS 10. Individual assessment scores were summarised using
frequency distributions and mean and standard deviations. Comparisons between baseline
and follow up scores were done using paired t-test for continuous scores (WHOQOL-BREF
and Health and Well-being Questionnaire) and McNamara Chi-square test for categorical
variables (GHQ12). Data were analysed with the two states combined and separately.

Value of the intervention from the participant and NGO perspectives

The Most Significant Change (MSC) method was used to evaluate the intervention from
the perspectives of the participants and the partnering NGOs. MSC is a qualitative,
participatory approach to monitoring and evaluation used in development projects [33]. In this study, we collected 'stories of change' from participants during the eighth
PAG meeting, and involved different stakeholders in systematic selection of the stories
that best captured what they considered to be the 'most significant change'. Reasons
for selecting particular stories were also documented. The point of MSC is that both
the content of the selected stories and the reasons for choosing them make the values
of the different stakeholders explicit, and this can be used to foster dialogue between
potentially competing perspectives, in this case that of the IDU widows and the NGOs.
As the MSC approach tends to elicit positive stories (in relation to the intervention),
this method is not used as an evaluation tool in isolation.

Initially, stories of change were collected from all participants who were willing
and able to provide them. The stories were told to the state-based research officers
(BD, TG) in private and were recorded and subsequently transcribed and translated.
Two panels were convened in each state: one participant panel consisting of two peer
facilitators, two widows, and an NGO liaison worker from each group (three groups
in each state), and one NGO panel consisting of two senior staff from each of four
NGOs connected to the project. The story selection process involved reading all of
the stories from the relevant state to the panel members who were given time to reflect
on each story and then, through a collective process, select the four stories that,
in their view, best represented the 'most significant change'. The two panels met
and made their selections independent of each other (Figure 1). Panel members were encouraged to discuss the reasons why they selected these particular
stories and this discussion was recorded, transcribed and translated. We were interested
in the similarities and the differences between the stories selected by the participant
and NGO panels, as well as similarities and differences in their reasons for selection.
Additionally all of the stories were thematically analysed. This is an inductive approach
that involves systematically coding and recoding the data in order to identify and
organise both explicit and implicit patterns embedded in the data.

Ethics and funding

This intervention study was funded by the United Kingdom's Department for International
Development (DFID) through the Research and Learning Fund. Ethics approval was obtained
from the University of Melbourne Human Research Ethics Committee (Australia) and the
Emmanuel Hospital Association Institutional Review Board (India) in early 2006. Participation
in the study was entirely voluntary, all participants provided informed consent and
confidentiality was assured.

Results

Participation and demographics

Seventy-four women participated in the first PAG meeting, and 59 women completed the
intervention (80% retention). The level of participation varied between NGOs (p =
0.04) and states (p = 0.002) (Table 2). The women were relatively young (mean age 32.5 years) and came from diverse ethnic
and religious backgrounds (Table 3). The average length of widowhood was 4.3 years and the average number of children
was 2.4. The majority of participants (81%) were not currently employed. Sources of
income for those not formally employed included small businesses, support from family,
sex work, and making handicrafts. Slightly more than half of the participants (53%)
had completed secondary school and 30% had undergone some form of tertiary education.
Nine percent of participants reported receiving no education. Although we did not
systematically collect information regarding the participants' HIV status and drug
use history, many of the women revealed their HIV positive status in the course of
the intervention, and a small proportion had a history of injecting drug use.

Changes in quality of life, mental health and somatic symptoms

In both states, all four Quality of Life domain scores increased across the course
of the intervention indicating a general trend towards improvement in their quality
of life (Table 3). The women experienced significant improvements in their physical and psychological
health, and their interaction with the environment was more positive after participating
in the intervention (p ≤ 0.05). While there was an increase in the social domain score,
this did not reach statistical significance. The Quality of Life results in Manipur
mirrored those for the group as a whole, but those in Nagaland were somewhat different
as even though they all improved, none reached statistical significance (Table 4).

Table 4. Mean scores (SD) for Quality of Life domains at the beginning and end of the intervention
by state

The results from the GHQ12 indicate that almost three-quarters of the group (70%,
49/70) were possibly experiencing a common mental disorder such as depression or anxiety
at baseline compared with 42% (24/57) at the end of the intervention (Table 4). This represents a significant decrease in the proportion likely to be experiencing
a common mental disorder (p < 0.01). Similar improvements were noted in both states.
Those who dropped out of the intervention compared to those who remained were no different
at baseline in relation to their GHQ12 scores and a range of demographic measures
(ethnicity, religion, education, employment and marital status).

In both states, the women experienced fewer somatic symptoms across the course of
the intervention (as indicated by lower scores). However, pain was the only symptom
that significantly decreased for the two states combined (p < 0.01).

In summary, these results indicate an overall improvement in several quality of life
and mental health parameters across the course of the intervention, although the patterning
of these improvements varied by state. Unfortunately, data were insufficient to conduct
a complete analysis of the effect of the intervention on participants' engagement
in HIV risk behaviours as too many of the respondents left the relevant questions
blank. Only a handful of participants openly engaging in sex work responded adequately
to these questions. This is discussed further in the Discussion section of the paper.

Thematic analysis of the Most Significant Change stories

Stories of change were collected from 33 participants in Manipur and 22 in Nagaland.
Analysis of the stories uncovered a range of themes, most of which aligned with the
socio-economic determinants of mental health i.e. social inclusion, freedom from discrimination,
and economic participation. This is not surprising as the intervention was somewhat
structured around these themes. Two additional themes were physical health and future
orientation. A sample story from each state can be found in Figure 2.

Social inclusion

Many participants described how joining the group helped them overcome social isolation
and provided them with a sense of belonging that was previously absent. The benefits
of meeting and building relationships with other women in the same situation were
frequently highlighted and the group became a source of nurturance and support for
many of the women, and a stepping stone into the wider society for some.

I felt that others discriminated against me as my husband died from drugs. This made
me ashamed and I never wanted to attend any social gatherings. I didn't want to interact
with others and this resulted in depression and stress and a feeling that life had
no value. Since I attended this meeting, it has encouraged me to interact socially.
I have even begun to attend the church and other social gatherings. It has been good
meeting other widows like me, who I never knew before, but now they have become my
friends with whom I can share my problems. (Manipur 11)

A lot of participants gained confidence in their own abilities as a result of having
to interact in a group setting.

Before I attended this PAG, I could never stand in a group and speak but during the
PAG sessions I had many opportunities to share my opinion and speak in the group,
which has helped me to realise some of my potentials. (Manipur 33)

Family conflict (mainly with in-laws) was one of the major sources of stress for the
women. Many felt that the intervention had provided them with skills to better manage
anger, thus enhancing their relationships with family.

My relationship with my family and in-laws has improved. Earlier I used to fight with
them because I have very negative thoughts about them. Now I understand that this
will only increase our worries and affect my mental health. I have been able to handle
my anger. After I stopped shouting, I have observed that even my children have stopped
fighting amongst themselves. This has helped me to strengthen my relationship with
my family and friends as well. (Nagaland 1)

The PAG meetings deliberately incorporated activities that were fun such as games
and singing, and this provided many of the women with a rare opportunity to experience
joy and pleasure.

The fun and laughter during the PAG has also helped me a lot. It is only here that
I experience fun and laughter. (Nagaland 20)

Finally, several of the participants said that they were inspired to help others.

I have been able to meet other people like me and have started thinking of helping
other people like me as well. I have been able to learn how to access resources and
this is helping me to manage my plans and finances better. I have already started
sharing my experiences and benefits with other widows. Now I have some peace of mind. (Nagaland 12)

Discrimination

The theme of discrimination against people with HIV and AIDS generally, and IDU widows
in particular, was evident in many of the women's stories. They described intense
feelings of anger in relation to perceived discrimination from both family and society.
Several of the women reported that learning to manage their anger allowed them to
better cope with this source of adversity.

Prior to joining the PAG, I had a strong resentment fermenting inside me for a very
long time. I would not be able to eat, sleep or do anything... nor take care of my
children... People do not respect us because we were are widowed very young. They
think that we do not have any other means of earning except by selling our body...
Thinking about these things made my resentment grow from bad to worse. It has been
about four months since I began attending this PAG meeting. I have realised that these
problems will not go away... I can not hope nor expect any of them to change, but
I can adjust with them. I need not brood over their attitude and let it affect my
life and my relationship with my children. I can control my anger and seek my own
course in life. Now I keep my priority concern on my children's welfare, so I've started
attending the parents meetings at my children's school. (Manipur 20)

Economic participation

This theme was connected to both an appreciation of the allowance received as compensation
for their travel and childcare costs, and a growing awareness of their collective
ability to form self help groups for income generation.

Our allowances are very helpful because most of us are income-less at home. It is
no longer necessary to demand money from the family as we can meet some of our needs
now. With this allowance I buy Raja [tobacco] and sell it to get some profit... and
I spend that on my other essential needs. With this allowance we have a sense of ownership
in the family. (Manipur 1)

There are changes in my work also. I go to the agricultural field and forest to earn
my livelihood. I was very shy and could not even think of doing something in the town.
But now I have the confidence and I have started selling vegetables in the market
and also go house to house. (Nagaland 9)

We do not have a voice, so we can become strong if we come together... We can start
income generation and share our problems. If we are able to generate income it will
help us. (Nagaland 13)

Improved physical health

Many women reported feeling much better physically and several had initiated contact
with service providers as a result of participation in the group. Additionally, the
relationship between physical and mental health was recognised by some women.

After coming to the meeting I realised that I am not alone and that has encouraged
me to become more productive. I have also started accessing free medical services
and medicines, which I never did even if I knew there were facilities available. I
attended a free health camp for the first time last month. (Nagaland 11)

Even my physical health has improved in the last two to three months. I used to have
severe gastric problems but now that has reduced. Being able to share and discuss
my problems with friends has lightened my mental worries. (Nagaland 9)

Future orientation

Many of the women commented that the intervention contributed to renewed feelings
of hope for the future and several appreciated the opportunity to create personal
goals.

Before all my hope was gone but this meeting has given me new hope. I was like a dead
soul, but now with this new hope I can carry on my life and my responsibility. This
way it improves my mental health. (Manipur 11)

Reasons for selecting stories

All stories were considered by the participant and NGO panels in each state, and each
panel selected the four stories that best represented the 'most significant change'.
The participant and NGO panels selected stories that were similar in thematic content,
although the emphasis given to the reasons for the significance of the stories varied.
The reasons the participant and NGO panel members give for selecting particular stories
make explicit the type of changes valued by the different stakeholders. The emphasis
given to different types of changes was reflected by the number of times they were
mentioned in the course of the discussion. From the perspective of the storytellers,
changes took place within themselves, and in relation to their interactions with the
group, their families, and the broader community. The changes in these four spheres
are summarised in Figure 3.

Figure 3.Categories of valued changes identified using the Most Significant Change method.

The participant panels particularly valued changes in the intra-personal, group and
familial spheres, while the NGO panels tended to focus a lot more on the importance
of changes located in the societal sphere.

Discussion

This participatory intervention study to promote the mental health of widows of IDUs
apparently had a positive impact on the widows' quality of life and their mental health.
However, the sustainability of the improvement and the links between this and their
engagement in HIV risk behaviours remain to be demonstrated.

While the physical, social and environmental domain scores of the quality of life
measure improved significantly, the change in the social domain score did not. Qualitative
findings, however, demonstrated improvements in social connectedness for the women.
Had the sample sizes been larger, the change in the social domain scores may also
have achieved statistical significance. For the women in Nagaland, the change in the
scores for all four domains was not significant. The Quality of Life scores at baseline
were higher among participants from Nagaland, and this together with the smaller sample
size may account for the non-significant change observed in that state.

While the intervention's positive impact on mental health as assessed by the GHQ12
is encouraging, identifying a high proportion of the group (70%) as potentially having
a common mental disorder (anxiety or depression) is a matter for concern. An overestimation
of this proportion is possible for technical reasons. The GHQ12 includes questions
about the presence of physical symptoms; as some of the women were HIV positive and
experiencing physical illness, their resulting higher scores may have resulted in
some instances of (mis)classification as 'cases'. On the other hand, the level of
distress among this vulnerable group is evident to those familiar with their situation,
and this finding is not surprising.

Given that women in India often express psychological distress as somatic symptoms
[28,29], the observed reduction in the proportion of IDU widows reporting pain raises the
possibility that this is connected to improved mental health, although the same improvements
were not apparent in relation to the other somatic domains.

During the MSC process the participant and NGO panels gave differing emphasis to the
reasons for selecting particular stories as representing the 'most significant change'.
The former tended to value changes in the intra-personal, group and familial spheres,
while the latter gave more focus to changes in the broader community sphere, perhaps
reflecting their focus on sustainability of programs. This has implications for the
design and evaluation of interventions. These will ideally meet the needs of both
program participants and implementers if the contribution to HIV prevention is to
be valued at all levels. The funding organisation is another stakeholder that could
be involved in the MSC process, and they may well have a different perspective again.
The MSC approach facilitates organisational learning for all connected to programs
that aim to create change for participants.

The intervention generally, and the MSC process specifically, enhanced awareness among
the NGO leadership of the struggles faced by IDU widows, especially those infected
with HIV. Many of the NGOs providing HIV-related services in north-east India are
male-dominated because the epidemic initially affected male IDUs predominantly. Prior
to the intervention, IDU widows were isolated and powerless, and struggled to gain
access to the few NGO programs relevant to them. Providing an opportunity for the
widows to come together around the theme of mental health promotion has helped them
to mobilise. Additionally, awareness of mental health as an important health issue
for all people, including those with HIV infection, has increased.

While the number of women participating in the intervention was relatively small and
the intervention relatively brief, these findings contribute to knowledge and understanding
about the use of participatory interventions to improve the mental health of vulnerable
women, and demonstrate the potential of this approach to contribute to HIV prevention.

The study has several limitations. As no control group met without receiving the structured
program designed to promote mental health, we cannot know to what extent the observed
improvements were related to the program content. The act of coming together may in
itself have induced the changes. The attrition in some groups was disappointing but
not unexpected given the stressful and at times unpredictable nature of the widows'
lives, and an overall retention rate of 80% is high in this context. The linguistic
and ethnic diversity and different literacy levels of the participants presented challenges
during the intervention and data collection (see below). While most of these were
overcome successfully with extra time, effort and research, we recommend that the
participants in future groups be relatively homogenous. In relation to the intervention,
we would also recommend that some HIV prevention education be included as even though
these women's husbands had mostly died from AIDS, their level of HIV knowledge was
poorer than expected. Extending the intervention to include training in advocacy and
community mobilisation is also worth considering.

A relatively generous allowance was paid to the women to cover travel and childcare
costs. This was important in motivating and recruiting women to participate in the
intervention at the outset. While we do not know the extent to which the allowance
influenced participation, six months after the last PAG meeting most of the groups
are still meeting and some have expanded their activities. No allowance is now paid
to the women, but support for the meetings is being given by NGOs.

Capturing sensitive information such as engagement in HIV risk behaviours proved to
be challenging. North-east India is characterised by deeply felt conservative values,
which are likely to have made it difficult for the widows to respond to questions
about paid or unsafe sex, even though we had processes in place to assure confidentiality.
The impact of improved mental health on engagement in HIV risk behaviours is therefore
difficult to assess. Further work is required to develop sensitive and valid measures
of sexual behaviour among groups such as these: including exploration of the women's
perspectives on non-threatening methods for data collection about sexual behaviours,
and trying other approaches such as participatory methods or individual narrative
interviews with a trusted peer interviewer. Developing more effective methods for
gathering information about sexual risk behaviours is essential for future research
into the relationship between mental health and engagement in HIV risk behaviours.

Finally, the data collection tools had to be translated into the local language and
back-translated. The meaning of individual questions in questionnaires such as the
WHOQOL-BREF are nuanced and therefore not easy to exactly translate into languages
that do not have the spectrum of words to communicate subtle differences in meaning.
Imphal and Churachandpur in Manipur are only two hours apart by vehicle, but they
do not share a common language, and two different translations were required for that
state. Some people are able to read Manipuri when it is written in Manipuri script,
while others can only read it in Bengali or transliterated Roman script. Nagamese
is a spoken language with no official written form. Accurate translation of the data
collection tools was an arduous task and further refinement and validation is warranted.
This is typical of the many challenges encountered when trying to undertake quality
research in remote settings.

Conclusion

This pilot intervention study used a range of innovative approaches to program design,
implementation and evaluation in order to reach a vulnerable group of women in a complex
development setting with high HIV prevalence. The findings demonstrate that a participatory
approach to mental health promotion can have a positive impact on the health and quality
of life of vulnerable women. The intervention would benefit from further trialling
and refinement and could be made available to other groups such as women living with
HIV, the wives of IDUs, and specific sub-groups of widows such as sex workers and
IDUs. Further research to evaluate the impact of the intervention on the lives of
vulnerable women and to investigate the role of mental health promotion as a strategy
for HIV prevention is warranted.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

HH, AD and MK were involved in conception of the study. HH, AD, MK and PC were involved
in design, implementation and data analysis of the study. BD and TG were involved
in the implementation and data analysis of the study. MK drafted the paper with contributions
from AD, HH and PC. All authors read and approved the final manuscript.

Table 5. Proportion of participants with a possible common mental disorder as assessed by GHQ12
(using 3/4 cut-off) at the beginning and end of the intervention by state

Table 6. Somatic complaints at the beginning and end of the intervention

Acknowledgements

The study was funded by the UK Department for International Development (DFID) through
the Research and Learning Fund. The authors would like to acknowledge the contribution
of the following north-east Indian organisations: Project ORCHID; Development Association
of Nagaland (DAN), Guardian Angel (GA), Lamka Rehabilitation & Research Centre Evangelical
Baptist Convention (LRRC), Manipur Network of Positive People (MNP+), Naga Mothers
Association HIV/AIDS Care and Support Hospice (NMA), Sneha Bhavan (SB) and the Emmanuel
Hospital Association. We are also very grateful to the following people: Dr B Langkham,
Dr Rebecca Sinate (Emmanuel Hospital Association); Mr Aviw-u Nienu (NMA); Mr Raphuba
Paul Chawang (DAN); Ms Leishipem Shingnai (GA); Ms Kim and Ms Bina (MNP+); Ms Hatnu
Simte (SB); Ms Biak Lun (LRRC); Ms Angela Rintoul (AIHI); and Ms N.Roopa (India).
We thank Dr Jessica Dart (Clear Horizon) for her assistance with the Most Significant
Change component of the study and Ms Suzanne O'Neill (Burnet Institute) for her contribution
to the project design. Finally, we want to warmly acknowledge the contribution made
by the peer facilitators and all the women who participated in the study. Without
their courage and determination it would not have been possible.

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